Basic Information
Provider Information | |||||||||
NPI: | 1245421312 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GRANT MEMORIAL HOSPITAL HOME INFUSION THERAPY SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | RT 4 AND 28 | ||||||||
Address2: |   | ||||||||
City: | PETERSBURG | ||||||||
State: | WV | ||||||||
PostalCode: | 26847 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | RT 4 AND 28 | ||||||||
Address2: |   | ||||||||
City: | PETERSBURG | ||||||||
State: | WV | ||||||||
PostalCode: | 26847 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3042571026 | ||||||||
FaxNumber: | 3042579622 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/05/2007 | ||||||||
LastUpdateDate: | 08/05/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BROSH | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PIC | ||||||||
AuthorizedOfficialTelephone: | 3042571026 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | RPH | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336H0001X | OP0551225 | WV | Y |   | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 5010549 | 01 |   | OTHER ID NUMBER | OTHER |